Introduction
Autonomy is an important value in medical ethics. Patients have a right to make decisions regarding the medical care they receive without being influenced by health care providers. Patient autonomy gives health care professionals the right to educate their patients but not to make medication/intervention decisions for the patients. The principle of respecting autonomy is related to allowing a patient to make decisions on whether to accept the proposed health intervention/medication or not. People with autism experience problems with communicating and behavior ( Reichow & Barton, 2018) . Just like other patients, autistic patients have a right to autonomy too. However, this right presents ethical issues in patients suffering from autism. This paper presents a discussion of an ethical dilemma related to autism and autonomy in medication.
Case Study
Jane was diagnosed with autism while aged five years. She received behavioral therapy for her symptoms until the age of fifteen. At fifteen, she started experiencing angry outbursts frequently. She frequently shouted at her friends, siblings, and parents. In addition, she would scream while in school. Her parents realized that she had turned irritable and in most cases, appeared depressed. A physician proposed an SSRI and an antipsychotic to help with the anger outbursts and irritated mood. At the age of eighteen years, Jane's cognitive ability can be said to be at the lower normal range. However, her ability to do her daily duties is, to a great extent, impaired, and her mother has to intervene in most cases. She has to be reminded and supervised to take care of herself. This includes medication, homework, and other routine activities such as brushing teeth.
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Jane also suffers from sensory overload. As a result of the condition, she is enrolled in an alternative school. During a check-up session, Jane says that she no longer wants to take medicine anymore. She says that she hates the medicines prescribed. Her parents say that the medicines make a significant difference in her symptoms. Her mother stated that they once tried to go off medication, and she went out of control. However, when she takes the medicines according to her mother, her irritation seems less, and she appears less annoyed. Jane said that she was sick of taking the drugs and she is an adult hence should be allowed to make her own decisions. She doesn't like the fact that her mother, who is also her legal guardian, makes decisions for her, especially when it comes to autism medication.
Key Points of the Dilemma
Autonomy is a crucial ethical concept in medicine that requires a special understanding of autism because it involves the prerequisite to make decisions and have the life that one wants to live. In this case, it involves decisions about whether to accept medication or not.
When autistic individuals turn 18 years, their parents become their legal guardians, and this, in most cases, deprives them of the chance to make their decisions and determine their lives.
Although a guardian may act for the best interests of an autistic patient, guardianship does not give them access to the same rights as other adults who are not suffering from autism.
The issue of autonomy is significant in people who have autism, most of whom do not have access to a chance for self-determination.
The capacity for people who have autism to accept or refuse medication is, in most cases, overlooked.
Appropriate accommodations and information can help people with autism understand medication options, determine the risks and benefits of medication and weigh them, and present a choice.
Key Terms Associated with Dilemma
Autism is a heterogeneous group of conditions that are characterized by problems in the ability to socialize, repetitive behavior, and communication, both in verbal and non-verbal means (Jung Lee et al., 2014).
Autonomy in medical and nursing practice refers to the right of adults who are competent to make decisions regarding the medical care that they receive (Playford et al., 2015). The principle requires the patient's consent before initiating treatment or medication.
Ethics from the medical field perspective refers to moral principles that use values in practice and research.
Maturity, as explained from a legal perspective, puts into consideration age, education, grades, discipline, and plans for the future (Playford et al., 2015).
Capacity refers to the general understanding of a person's situation and all the gains and risks that come with the intervention involved the ability to give a choice, and the ability to think logically.
Analysis of the Dilemma
In the case study, the parents of Jane appear to have the best of interests for Jane. The medication that Jane uses helps her in her mood, irritation symptoms, and other daily activities. After attempting to take the medication off, Jane's parent stated that the moods and anger outbursts became uncontrollable. The symptoms became better after resuming medication. She refuses to take medication because of the side effects they have on her and the fact that she also doesn't like taking the medication, which she has to take every day. Different states have different conditions set for people who have autism.
Regardless of the state where Jane and her family live, her case shows that she does not have the capacity or the maturity to decline medication. Her education level and ability to perform her daily activities show that she does not have the maturity to make crucial decisions related to her health, such as medication. In addition, it appears that she has no clear understanding of the risks and gains of the medicines administered to control the condition. In addition, it appears that Jane does not show logical thinking related to why she is refusing treatment. On the other hand, Jane is attained the legal adult age. She is eighteen years old. Jane has the legal right to have her own decisions related to the medication.
For any medical practice to be termed ethical, it has to respect all the four main principles. The principles include autonomy, justice, beneficence, and non-maleficence (Playford et al., 2015). In the case study involving Jane, autonomy conflicts with justice, beneficence, and non-maleficence. Autonomy requires that the patient be granted the autonomy of thought, motive, and action in decisions related to care. However, to make an informed decision, a patient has to understand every benefit and risk involved in the treatment/medication. Justice requires that procedures align/comply with the existing laws and fair to all the people involved. Beneficence requires that treatment be offered to do well to the patient. Non-maleficence, on the other hand, demands that treatment/medication should not harm the patient or other people in society.
In the case of Jane, although she is of legal age to make her own decisions, the fact that her capability to make decisions is impaired presents a dilemma. In addition, the health care provider should practice beneficence. The medications prescribed for Jane by the health care provider are meant for good. By taking the medications, she can carry out some of her daily activities and reduce irritation and moods. However, she does not want to take the medications, and this presents the issue of autonomy. In most cases, health care professionals do not have control over the non-maleficence duty. Some medications may cause some side effects like in the case of Jane. However, the benefits of the medication prescribed for Jane outweigh the risks. Currently, there exists no standard treatment for autism. The existing guidelines involve trying different SSRIs to establish the ones that have fewer side effects or the more tolerable ones ( Oono, Honey, & McConachie, 2013 ). By ensuring beneficence, justice, and non-maleficence and ignore autonomy, the practice of going against the wish of Jane regarding the medication would be unethical. On the other hand, by ensuring non-maleficence to avoid harm caused by Jane during her anger outburst fits and ignore the other principles, the action would still be considered unethical.
Application of Kant's Categorical Imperative to the Dilemma
The categorical imperative developed by Immanuel Kant offers several requirements that motivation has to fulfill for an action to be termed a moral duty. When implemented, a categorical imperative becomes a person's moral responsibility to implement the action in any situation (Playford et al., 2015). According to Kant, when implementing an action, the person's main motive should be the duty. A person can determine duty by applying reason. Kant states that reason is objective and also universal for human beings, and as a result, it can be relied upon in moral theory (Playford et al., 2015). Immanuel Kant proposes three formulations related to the categorical imperative.
Kant's first formulation proposes that human beings should only implement an action that can be made universal. The action should not present a contradiction in making it universal. If doing so is not possible, then it can be logically assumed that such action is immoral because it is against reason. In the case of Jane's refusal to take medication, the health care provider should consider the action to be taken from a universal point of view. The health care provider should ask him/herself if the action of allowing Jane to keep off medication as she demands can be made universal. The other action which is following the parents' decision to have her take the medicines should also be considered from the point of universalism too. Going by this formulation, the action of allowing Jane to keep the medication would mean that the action can be applied to patients like Jane in similar situations throughout the world. Having her take the medicines against her wish means that the action can be applied on a universal basis. However, if the actions cannot be made universal, then it means that they are not ethical. According to Kant, if a rule cannot be applied universally, other people cannot do the same freely from the moral principle. Kant believes in autonomy and states that it is important in being moral.
The second formulation developed by Kant proposes that people should not be treated as a means but as an end. According to Kant, one should not use others as a means to an end because this is exploiting their rationality (Playford et al., 2015). Every person should be valued as rational. Therefore, the healthcare provider should not use Jane and her parents as a means but as an end. Thus, even though Jane's capability is impaired, the health care provider should not see her as a means. Besides, although Jane's parents want to have their daughter take medication, the health care provider should not exploit their rationality regarding Jane's situation. The last formulation states that people should always act on the belief that others will follow the same rule that one makes through actions. The health care provider should establish if the action chosen can be followed as a rule by other people. If the action chosen by the health care provider passes all the three formulations, it can be termed considered a categorical imperative, and therefore it is both right and moral duty.
Application of Utilitarianism to the Ethical Dilemma
From a utilitarian approach, a moral decision is the one that produces the greatest amount of benefit for the majority (Playford et al., 2015). The approach is also referred to as the consequentialist perspective. The outcomes of an action determine the morality of the action. In the case study of Jane, the health care provider would assess the actions to identify the one that produces the greatest amount of benefits for the majority and implement it. Allowing Jane autonomy would mean that she would go without medications. From a utilitarian approach, this would cause harm to Jane, her parents, siblings, school mates, and other people that she would encounter because of her condition. On the other hand, ignoring the patients' autonomy and make her take the medication would produce the most significant benefit and for the majority that includes her family, Jane, schoolmates, and the society at large, and this would be a moral action from a utilitarian perspective. The benefits and harms inform this method of action according to evidence (Playford et al., 2015).
There exist two versions of the utilitarian approach. These are act and rule utilitarianism. Act utilitarianism involve decisions in each case arrived at through assessing benefits and harms enhancing overall better outcomes (Playford et al., 2015). Decisions for each patient is based on the balance between harm and benefits without considering experience or evidence in the past. Rule utilitarianism, on the other hand, the decision is based on preformed rules that are informed by evidence (Playford et al., 2015). Rule utilitarianism offers better guidance compared to act utilitarianism when making decisions. From this perspective, an ethical decision complies with moral codes causing better outcomes.
Preferred Approach to the Dilemma
Although utilitarianism seems appealing, it makes patients constrained when health care providers make decisions hence affects the primary ethical principles. Besides, utilitarianism can be accommodated in cases where the patient is competent enough to be involved in the health care decision-making process while raising moral dilemmas in cases where patients are not competent like in the case of Jane, who is suffering from autism. Different from the utilitarian approach, the kind of action determines the categorical imperative approach by Immanuel Kant, a decision's morality. This means that harm is not acceptable, regardless of the consequences (Playford et al., 2015). The decision made from this approach can be appropriate for the person involved but may not be suitable for society. In the case of Jane, the decision to allow autonomy may not be suitable for her but not for the people who are affected by her actions as a result of her condition.
Of the two methods, Kant's categorical imperative would be appropriate for the case study. Since the patient seems not to understand the benefits and risks involved, the health care provider can educate her so that she can make an informed decision. Also, different medicines can be presented so that the best option that produced fewer side effects for the patient is chosen (Levy & Hyman, 2008). By trying to educate the patient, she will feel a part of the decision making process regarding her health care. The health care provider should create an environment that helps in successful communication. Just like people who are not autistic, autistic people’s difficulty in communication depends on the context (Gernsbacher Stevenson & Dern, 2017). By doing so, the decision made will be out of the goodwill for all the people involved. The approach does not give room for harm like it is the case with utilitarianism, which gives room for some harm. The imperative approach would help appropriately solve the ethical dilemma.
Conclusion
Most people who have autism require practical assistance with day to day activities such as planning. Besides, they also need help in making decisions due to the limited capability to do so. However, their autonomy should not be overlooked. Like in the case of Jane, appropriate methods of dealing with the ethical dilemma should be applied to ensure that the patient's autonomy is also respected. The motive should be to cause better outcomes appropriate for all the people affected. Kant's categorical imperative would be the best approach to deal with the ethical dilemma presented.
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